Recurrence after successful parathyroidectomy—Who should we worry about?

Shirali, Aditya S.; Wu, Seng-Tang; Chiang, Yi Ju; Graham, Paul H.; Grubbs, Elizabeth G.; Lee, Jeffrey E.; Perrier, Nancy D.; Fisher, Sarah B.

doi:10.1016/j.surg.2021.06.035

Cited by 6 publications

(10 citation statements)

References 22 publications

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“…In addition, in patients who underwent minimally invasive parathyroidectomy, at least 1 pre-operative imaging and/or findings inconsistent with intraoperative findings are associated with an increased risk of recurrence in patients (hazard ratio 4.93, 95% confidence interval 1.25–16.53, p=0.016). [ 57 ] Similarly, in another study, Ca levels >9.7 mg/dL at 6 months and an increase in PTH with normocalcemia at 6 months were found to be independent risk factors for late recurrence. [ 11 ]…”

Section: Predictive Factors For Perhpt and Rechptmentioning

confidence: 87%

“…According to the study of Shirali et al [ 57 ] ; age >66.5, calcium level 9.8 mg/dL and PTH 80 pg/mL at 6 months are independent factors related to the increased risk of recurrence. In addition, in patients who underwent minimally invasive parathyroidectomy, at least 1 pre-operative imaging and/or findings inconsistent with intraoperative findings are associated with an increased risk of recurrence in patients (hazard ratio 4.93, 95% confidence interval 1.25–16.53, p=0.016).…”

Section: Predictive Factors For Perhpt and Rechptmentioning

confidence: 99%

“…In some studies, it was associated with early postoperative NCePTH recurrence, while in some studies it was associated with NCePTH recurrence at 6 months. [ 11 , 57 - 59 ]…”

Section: Verification Of Persistence or Recurrencementioning

confidence: 99%

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Persistent and Recurrent Primary Hyperparathyroidism: Etiological Factors and Preoperative Evaluation

Uludağ¹

2023

Sisli Etfal

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Primary hyperparathyroidism (pHPT) is the most common cause of hypercalcemia and currently the only definitive treatment is surgery. Although the success rate of parathyroidectomy is over 95% in experienced centers, surgical failure is the most common complication today. Persistent HPT (perHPT) is defined as persistence of hypercalcemia after parathyroidectomy or recurrence of hypercalcemia within the first 6 months, and recurrence of hypercalcemia after a normocalcemic period of more than 6 months is defined as recurrent HPT (recHPT). In the literature, perHPT is reported to be 2–22%, and the rate of recHPT is 1–15%. perHPT is often associated with misdiagnosed pathology or inadequate resection of hyperfunctioning parathyroid tissue, recHPT is associated with newly developing pathology from potentially pathologically natural tissue left in situ at the initial surgery. In the pre-operative evaluation, the initial diagnosis of pHPT and the diagnosis of perHPT or rec HPT should be confirmed in patients who are evaluated with a pre-diagnosis (suspect) of perHPT and recHPT. Surgery is recommended if it meets any of the recommendations in surgical guidelines, as in patients with pHPT, and there are no surgical contraindications. The first preoperative localization studies, surgical notes, operation drawings, if any, intraoperative PTH results, pathological results, and post-operative biochemical results of these patients should be examined. Localization studies with preoperative imaging methods should be performed in all patients with perHPT and recHPT with a confirmed diagnosis and surgical indication. The first-stage imaging methods are ultrasonography and Tc99m sestamibi single photon tomography Tc99mMIBI SPECT or hybrid imaging method, which is combined with both single-photon emission computed tomography and computed tomography (SPECT/CT). The combination of USG and sestamibi scintigraphy increases the localization of the pathological gland. In the secondary stage, Four-Dimensional computer tomography (4D-CT) or dynamic 4-dimensional Magnetic Resonance Imaging (4D-MRI) can be applied. It is focused on as a secondary stage imaging method, especially when the lesion cannot be detected by conventional methods. Positron Emission Tomography (PET) and PET/CT examinations with 11C-choline or 18F-fluorocholine are promising imaging modalities. Invasive examinations can rarely be performed in patients in whom suspicious, incompatible or pathological lesion cannot be detected in noninvasive imaging methods. Bilateral jugular vein sampling, selective venous sampling, parathyroid arteriography, imaging-guided fine-needle aspiration biopsy, and parathormone washout are invasive methods.

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Section: Predictive Factors For Perhpt and Rechptmentioning

confidence: 87%

Section: Predictive Factors For Perhpt and Rechptmentioning

confidence: 99%

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Persistent and Recurrent Primary Hyperparathyroidism: Etiological Factors and Preoperative Evaluation

Uludağ¹

2023

Sisli Etfal

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“…A recent large study from Taiwan including 522 patients after parathyroidectomy (mostly MIP) with a median follow-up of 2.5 years found, by multivariate analysis, that age > 66.5 years, serum calcium ≥ 9.8 mg/dL and parathyroid hormone ≥ 80 pg/mL at 6 mo were risk factors for recurrence (rate of 2.5%); after MIP, the discrepancy of at least one preoperative imaging study with intraoperative findings was a risk factor[ 47 ].…”

Section: Discussionmentioning

confidence: 99%

“…Its disadvantages include the limited effectiveness in the presence of supernumerary glands and the possibility of double adenoma[ 4 , 9 ]. With the current advancements in diagnostic adjuncts for accurate abnormal parathyroid localization, surgery has moved from BNE to a focused open parathyroidectomy or unilateral neck exploration as well as to a minimally invasive parathyroidectomy (MIP) that necessitates even more accurate preoperative localization[ 22 , 25 , 47 - 49 ].…”

Section: Managementmentioning

confidence: 99%

Update on the current management of persistent and recurrent primary hyperparathyroidism after parathyroidectomy

Pavlidis¹,

Pavlidis²

2023

World J Clin Cases

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Primary hyperparathyroidism (pHPT) is the third most common endocrine disease. The surgical procedure aims for permanent cure, but recurrence has been reported in 4%-10% of pHPT patients. Preoperative localization imaging is highly valuable. It includes ultrasound, computed tomography (CT), single-photon-emission CT, sestamibi scintigraphy and magnetic resonance imaging. The operation has been defined as successful when postoperative continuous eucalcemia exists for more than the first six months. Ongoing hypercalcemia during this period is defined as persistence, and recurrence is defined as hypercalcemia after six months of normocalcemia. Vitamin D is a crucial factor for a good outcome. Intraoperative parathyroid hormone (PTH) monitoring can safely predict the outcomes and should be suggested. PTH ≤ 40 pg/mL or the traditional decrease ≥ 50% from baseline minimizes the likelihood of persistence. Risk factors for persistence are hyperplasia and normal parathyroid tissue on histopathology. Risk factors for recurrence are cardiac history, obesity, endoscopic approach and low-volume center (at least 31 cases/year). Cases with double adenomas or four-gland hyperplasia have a greater likelihood of persistence/ recurrence. A 6-mo calcium > 9.7 mg/dL and eucalcemic parathyroid hormone elevation at 6 mo may be associated with recurrence necessitating long-term follow-up. 18F-fluorocholine positron emission tomography and 4-dimensional CT in persistent and recurrent cases can be valuable before reoperation. With these novel advances in preoperative imaging and localization as well as intraoperative PTH measurement, the recurrence rate has dropped to 2.5%-5%. Six-month serum calcium ≥ 9.8 mg/dL and parathyroid hormone ≥ 80 pg/mL indicate a risk of recurrence. Negative sestamibi scintigraphy, diabetes and elevated osteocalcin levels are predictors of multiglandular disease, which brings an increased risk of persistence and recurrence. Bilateral neck exploration was considered the gold-standard diagnostic method. Minimally invasive parathyroidectomy and neck exploration are both effective surgical techniques. Multidisciplinary diagnostic and surgical management is required to prevent persistence and recurrence. Long-term follow-up, even up to 10 years, is necessary.

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Long‐term Cure of Primary Hyperparathyroidism After Scan‐Directed Parathyroidectomy: Outcomes From A UK Endocrine Surgery Unit

Patel

Mihai

2022

World j. surg.

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Background Two‐decades ago, the advent of sestamibi scintigraphy led to an enthusiastic acceptance of minimally invasive parathyroidectomy (MIP) in most surgical centres. More recently, concerns have been raised about the efficacy of limited neck exploration and some surgeons proposed bilateral neck exploration to be (once again) the gold standard operation for primary hyperparathyroidism in 2020s. Methods A departmental database was used to identify patients who had MIP after concordant dual localisation with sestamibi scintigraphy and ultrasound scans. Long‐term follow‐up data were obtained from electronic patient records to ascertain any further treatment for recurrent disease and confirm most recent biochemical status. Patients with negative localisation scans and those with familial disease were excluded from analysis. Results Between June 2001 and August 2014 a total of 404 patients (108 M:296F, median age 63 years, range 17–90 years) underwent MIP and had normalisation of calcium in first 6 weeks after the operation. Information on electronic patient records were missing in 14 patients; therefore, data on 390 patients were analysed. During median follow‐up of 78 months (IQR: 21.25–111.75 months), 375 patients had normocalcaemia (2.36 mmol/L, IQR: 2.29–2.44 mmol/L) at a median 75 months, (IQR: 20–118 months) after their operation. Overall, 15 (3.85%) patients had biochemical evidence of recurrent disease (2.70 mmol/L IQR: 2.63–2.75 mmol/L) at 92 months (Range: 6–196) after initial operation. Of these, 5 (1.28%) patients underwent a second parathyroid procedure. Conclusion Recurrence after scan‐directed unilateral neck exploration occurred in 4% of patients after a long disease‐free interval. Only one patient had recurrent disease within 1‐year of primary surgery. The data suggest that bilateral neck exploration at the time of initial operation, in this selected cohort, is unlikely to have uncovered multi‐gland disease and prevent disease recurrence. Focused parathyroidectomy in patients with convincing localisation studies should continue.

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Recurrence after successful parathyroidectomy—Who should we worry about?

Cited by 6 publications

References 22 publications

Persistent and Recurrent Primary Hyperparathyroidism: Etiological Factors and Preoperative Evaluation

Persistent and Recurrent Primary Hyperparathyroidism: Etiological Factors and Preoperative Evaluation

Update on the current management of persistent and recurrent primary hyperparathyroidism after parathyroidectomy

Long‐term Cure of Primary Hyperparathyroidism After Scan‐Directed Parathyroidectomy: Outcomes From A UK Endocrine Surgery Unit

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